Stapled, uncut gastroplasty for hiatal hernia: 12-year follow-up

A total of 82 patients with gastroesophageal reflux were consecutively treated with stapled, uncut gastroplasty and complete fundoplication over a 12-year period. The conditions treated included symptomatic reflux; esophageal stricture; massive hernia; collagen esophagus; short esophagus; Barrett's esophagus; recurrent, massive bleeding or anemia; small gastric remnant after gastrectomy; and acute volvulus. The transthoracic approach of stapled, uncut gastroplasty gives superb exposure. Outstanding features of the procedure are the safety and versatility resulting from the small amount of fundus required, no need either to ligate short gastric vessels or to suture the esophagus itself, and preservation of anatomical continuity between the wrapping fundus and the wrapped gastric tubular segment. There have been no deaths and no cases of anatomical or symptomatic recurrence in the series. Complications included some nondebilitating and mainly self-limiting symptoms.     

Supraclavicular thoracotomy for diagnosis of apical lung and superior mediastinal lesions.

Despite the use of mediastinoscopy, anterior mediastinotomy, transcarinal biopsy, needle biopsy, and transbronchial fluoroscopic brushing, thoracotomy is necessary to obtain tissue for diagnosis in patients suspected of having carcinoma of the lung. A technique we have employed is exploratory thoracotomy, as described for the approach to cervical and upper dorsal sympathetic ganglion, with entrance into the pleural space through a supraclavicular incision. Five patients, 3 with marginal pulmonary function and 2 with brachial plexus and upper mediastinal or vertebral involvement, had tissue diagnosis of lung carcinoma by this method without postoperative complication. Supraclavicular thoracotomy offers a safe, easy, and definitive method of tissue diagnosis of apical lung and superior mediastinal lesions.     

Constrictive pericarditis.

A patient with constrictive pericarditis following an open-heart operation without sepsis is discussed. In the absence of sepsis, it has been widely held that this complication does not develop following an open-heart procedure. The fatal outcome in this patient could have been avoided had such an association been known.     

Myoplasty for closure of tracheobronchial fistula

Myoplasty techniques are described in which pedicle or free muscle grafting is used in the closure of either acute or chronic bronchopleural fistula. The pectoralis major muscle, the intercostal muscle pedicles, or the free graft is used according to specific indications.     

Is Reperfusion Injury from Multiple Aortic Cross-Clamping a Current Myth of Cardiac Surgery?

Four hundred eighty adult patients undergoing cardiac operations had systemic and topical hypothermic anoxic arrest supplemented with potassium chloride pharmacological cardioplegia in a prospective randomized study. Group 1 (217 patients) had continuous aortic cross-clamping and one single anoxic arrest period during the cardiac portion of the operation which resulted in a transmural myocardial infarction rate of 8.3%, myocardial “injury” incidence of 12.4%, 4.6% cardiac-related deaths, 11.5% and 24.8% severe and malignant ventricular arrhythmias, 21.7% rate of severe vasopressor usage, a mean group serum glutamic oxaloacetic transaminase (SGOT) of 140 ± 39 IU, and a mean group lactic dehydrogenase (LDH) of 636 ± 78.2 IU. Group 2 (263 patients) had intermittent aortic cross-clamping with multiple reperfusion intervals, which resulted in a significantly lower incidence of transmural myocardial infarction at 1.9% (p < 0.01), rate of myocardial injury at 5.66% (p < 0.02), number of cardiac deaths at 0.76% (p < 0.02), 8.7% and 16.0% severe and malignant ventricular arrhythmias (p < 0.01), severe vasopressor utilization rate of 14.3% (p < 0.05), mean group SGOT at 72.0 ± 3.1 IU (p < 0.01), and mean group LDH at 471.0 ± 12.3 IU (p < 0.05) than Group 1. These results do not support the contention that intermittent aortic cross-clamping in conjunction with hypothermia and pharmacological cardioplegia leads to increased clinical cardiac damage compared with continuous aortic cross-clamping. The converse is implied, in that the anoxic heart may benefit from the physiological effects of briefly reperfused oxygenated blood.     

Factors influencing patency of saphenous vein grafts.

To determine factors affecting saphenous vein graft patency, 218 grafts in 66 unselected patients were studied angiographically 1 year after operation. Fourteen variables were extracted from the angiograms, electrocardiograms, and intraoperative flow measurements to assess their predictive value. Preoperative coronary vessel diameter and degree of proximal stenosis measured angiographically correlated significantly with graft patency. Graft patency for vessels greater than 1.5 mm in diameter with greater than 70% stenosis was 93% (98 out of 105). Vessel size at operation and the presence of reactive hyperemia greater than 20 ml per minute also correlated significantly with graft patency. Reactive hyperemia increased significantly as the severity of the vessel stenosis proximal to the graft increased, thus suggesting a mechanism for the improved patency rate of grafts to more stenotic vessels. The patency rate of the end-to-side component of a continuity graft (left anterior descending coronary artery and diagonal or marginal artery in 1 graft) was 100% and of the side-to-side component, 77%. This study shows that the patency rate for saphenous vein grafts compares favorably with the reported patency for internal mammary grafts when critical factors such as vessel size (greater than 1.5 mm) and degree of stenosis (greater than 70%) are considered in bypass selection.     

Early clinical experience with the rechargeable cardiac pacemaker

After five years of laboratory development and experimental testing in animals, a rechargeable cardiac pacemaker powered by a specially designed nickel cadmium power cell was ready for human use. The bipolar coaxial pacing catheter connects to the pulse generator with a twist-lock mechanism, obviating the need for tools or ties. The small size of the pulse generator makes it easier to implant than conventional units. Recharging is performed by the patient at home for 90 minutes a week. This report details the early clinical experience with 26 patients who received this unit. All units are functioning and recharging according to specifications, and further clinical evaluation is now under way.     

Effect of repeated aspirin administration on the gastric mucosal barrier and cell turnover.

The effect on the gastric mucosa of repeated administration of aspirin was studied by measuring gastric mucosal permeability, blood loss, and cell turnover. Cell turnover was increased after a lag phase but this did not affect the increase in gastric mucosal permeability produced by the aspirin. It is suggested that the increase in cell turnover may account for the observed resistance to mucosal erosions that develops after repeated aspirin administration, but that the continued presence of a damaged and leaky gastric mucosal barrier accounts for the failure of mucosal resistance to confer significant benefit in the form of protection from the hemorrhagic consequences of aspirin ingestion.     

Effects of indomethacin on hemodynamics of dogs in refractory hemorrhagic shock.

We examined the effects of indomethacin upon anesthetized control dogs and dogs in refractory hemorrhagic shock. Systemic arterial pressure, central venous pressure, cardiac output, and blood flow to the kidney, the heart, the brain, a small intestinal segment, and a piece of skeletal muscle were measured. Systemic vascular resistance and resistances of the vascular beds of the kidney, the heart, the brain, a small intestinal segment, and a piece of skeletal muscle were calculated. Blood flow distribution within the renal cortex was also examined. Indomethacin treatment had little effect upon dogs that were not in shock. Blood flow to the skeletal muscle was decreased. There was also a redistribution of blood flow within the renal cortex with a greater proportion of renal cortical flow going to the outer cortex. However, systemic vascular resistance, cardiac output, and blood flow to the heart, kidneys, brain, and small intestine were unchanged.The refractory shock state was characterized by low systemic arterial pressure and cardiac output with vascular resistance identical to control. Blood flow to the kidney and brain appears to be decreased while coronary flow is maintained. In addition, the ratio of outer renal cortical blood flow to inner renal cortical blood flow, which in the control dog was about 1.5, decreases to 1.Indomethacin treatment largely reversed the hypotension of refractory shock. The increase in arterial pressure following indomethacin treatment is the result of an increase in systemic vascular resistance. Indomethacin treatment had no effect upon cardiac output. The vascular resistances of the kidney, heart, brain, and small intestine increased following treatment of dogs in refractory shock with indomethacin. Renal blood flow was decreased 57%. The renal cortical blood flow distribution was shifted toward the outer cortex as in the controls.Substances dependent upon prosta glandin synthetase may be involved in the hypotension that is characteristic of refractory hemorrhagic shock and may be important in maintaining blood flow to the kidneys and gut.     

Parietal and septal atrioplasty for total correction of anomalous pulmonary venous connection with superior vena cava

An operative procedure is described for correction of anomalous drainage of the right pulmonary veins into the superior vena cava. The procedure is technically simple and has the advantage of providing ample drainage of the pulmonary veins and superior vena cava without resorting to the use of prosthetic materials. Four case reports are presented.     

Surgical Treatment in Ebstein's Malformation

Between January, 1967, and July, 1981, 24 patients with Ebstein's malformation underwent surgical repair. Sixteen had tricuspid valve replacement; 8 did not. All interatrial communications were closed. Two patients had plication of atrialized ventricle. Twenty had dysrhythmias; these were surgically treated in 4. Four patients (17%), each with valve replacement, died in the hospital (70% confidence limits, 9-28%); 3 of these were among the 6 patients who were preoperatively in New York Heart Association Functional Class IV. There were 3 late deaths, 1 from noncardiac causes and 2 from persistent tricuspid regurgitation in patients without valve replacement. No late deaths or valve-related complications occurred in the valve replacement group. Dysrhythmias remain a problem, although most patients are symptomatically improved after operation.This experience suggests that good early and late results are obtained with replacement of incompetent tricuspid valves if this is done before advanced symptomatic deterioration, that plication rarely is necessary, and that rhythm disturbances should be recognized and appropriately managed.     

Isthmus flap aortoplasty: an alternative to subclavian flap aortoplasty for long-segment coarctation of the aorta in infants

The ideal operation for infants with coarctation of the aorta remains controversial. Subclavian flap aortoplasty is the most popular technique for this age group. The 5 to 20% recurrence rate is attributed to regrowth of the coarctation web or inadequate length of the subclavian flap, particularly when the aortic isthmus is long and narrow. Severe arm ischemia following subclavian flap aortoplasty, although rare, is a disturbing complication. The purpose of this study is to report the results with a new technique we call isthmus flap aortoplasty for coarctation of a long segment of the aorta in infants. This technique avoids the limitations of subclavian flap aortoplasty. A short segment of aorta, including the ductal entrance and coarctation web, was resected in 4 infants (mean age, 35.5 days) with long-segment coarctation. The posterior wall of the long isthmus was opened longitudinally to the level of the transverse aortic arch. The descending aorta was mobilized and advanced to the level of the aortic arch where the posterior half was sutured. The anterior flap of attached isthmus was then sewn into a longitudinal incision made in the anterior wall of the descending aorta. All infants survived this procedure and had no gradient at completion of the repair. The mean transconduit gradient at rest was zero and rose to 7.0 +/- 0.93 mm Hg after angiography at a mean follow-up of 42 months. Aortograms demonstrated that the reconstructed area had grown in girth and attained a normal caliber in each child.(ABSTRACT TRUNCATED AT 250 WORDS)     

The relationship of glucagon and insulin to sequential changes in metabolic fuel utilization in shock

Previous studies in the dog have demonstrated significant alterations in the mobilization of metabolic fuel during shock. In particular, mobilization of depot fat is markedly depressed. The present study examines the sequential utilization of nonlipid fuels over a 24-hr shock period. Metabolic rates were unchanged from controls. Skeletal muscle glycogen fell exponentially from 7.0 ± 0.5 to 2.7 ± 0.2 mg/g (P < 0.001) after 24 hr of shock. Protein breakdown as reflected by urea production was linear throughout the period and increased 50% over controls (P < 0.001). Lactate levels did not reflect changes in metabolic rate but fell to nearly normal levels once muscle glycogen was depleted. The contribution of CHO and protein combined to CO₂ production fell from 70% in early shock to 42% in the final 12 hr of the 24-hr shock period. This compares to 23% in controls. Protein catabolism alone accounted for an average of 32% of CO₂ production in shock. While insulin levels rose slightly in early shock and then fell, glucagon rose rapidly in the first 5 hr of shock and then remained significantly and constantly elevated throughout the entire shock period. The insulin-glucagon molar ratio remained in the severely catabolic range throughout.     

Threshold burning effects on distant microcirculation. IV: Development of an in vitro method for demonstrating vaso-activity in postburn plasma.

Following full-thickness, 730°C contact burns of rabbits' flanks, significant omental arteriolar constriction was observed in vivo. Plasma from burned subjects induced virtually identical omental arteriolar constriction when injected into unburned rabbits. In order to allow in vitro study of fractionated post-burn plasma, we devised a method for measuring the stress of rabbit aortic strips challenged with rabbit plasma. A statistically significant constriction and increase in stress occurs in the aortas of rabbits challenged with their own fresh or frozen-thawed postburn plasma. This study validated our previous in vivo work and provides a reliable in vitro method for evaluating fractionated, burned plasma in an attempt to identify the vaso-constrictive principle.     

Surgical correction of refractory reflux esophagitis using the standard unmodified Belsey Mark IV technique

The treatment of symptomatic hiatus hernia unresponsive to medical treatment has been refined in the last decade. The work of Hill and colleagues in investigating the pathophysiology of this problem, and the anatomical techniques developed by Dr. Nissen and Mr. Belsey, have reduced the recurrence rate in the surgical management of symptomatic hiatus hernia to the point where it is at least as low as that for surgically treated duodenal ulcer. The most commonly employed methods of surgical repair for symptomatic hiatus hernia are those advocated by Drs. Nissen and Hill and Mr. Belsey, which are superior to the many unmonitored methods employed in the past. Recently, the use of modifications of these techniques has been reported in the literature with short follow-up studies. The current communication relates one surgeon's experience treating 85 consecutive patients with refractory reflux esophagitis using the standard unmodified Belsey Mark IV repair as originally described by Mr. Ronald Belsey of Bristol, England. Details of this repair are presented.     

Pericardial fluid gas analysis in hemorrhagic pericardial tamponade.

Nine patients with hemorrhagic pericardial tamponade were studied to determine the localizing value of gas analysis of pericardial fluid in therapeutic pericardiocentesis. The aspirate and the central venous blood was analyzed simultaneously for partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), and hematocrit at the time of pericardiocentesis. In all 9 patients the difference in hematocrit between the pericardial fluid and the central venous blood was not significant. The PCO2 of pericardial fluid was significantly higher than that of central venous blood (p less than 0.025). The PO2 of pericardial fluid was consistently and significantly lower than that of central venous blood (p less than 0.005). We conclude that in patients with hemorrhagic pericardial tamponade, the simultaneous measurement of PO2 and PCO2 of central venous blood and pericardial fluid is a useful rapid bedside method to confirm the site of aspiration during pericardiocentesis. The PO2 determination is statistically the best discriminator between the two fluids in this setting.     

Microsurgical anatomy of the optic canal: correlates to optic nerve exposure

A new technique for exposure of the optic canal is described. The optic canal region is mapped and measurements under magnification of the anatomic landmarks are made. Magnification will enhance and facilitate exposure and increase the safety during exposure of the optic nerve. This is a preliminary report of our work and we hope to be ready for the appropriate clinical situation, when it arises, to apply our knowledge which is based on this report. This syndrome is rare and any achievements gained will help the patient with such a devastating clinical problem.